Armenian Infants Saved from a Lifetime of Blindness

Roger Ohanesian received an emergency phone call — it was the middle of the night. The director of the Armenian ROP (Retinopathy of Prematurity) Clinic in Yerevan, Dr. Tadevos Hovhannisyan, was calling. He told Roger there were 11 infants and seven children under the age of five who required immediate eye surgery. If they were not treated they would lose vision in one or both of their eyes and be fated to a lifetime of blindness. Because Armenia’s ROP Clinic is the only one in the Caucuses and the surrounding regions with the ability to perform this very challenging surgery some of the infants were from other countries.

After learning about the situation from Dr. Hovhannisyan, Dr. Ohanesian set out to plan his trip to Armenia. He needed to leave immediately, but first it was essential for him to find a highly skilled pediatric retinal specialist (fewer than 30 worldwide) who would join him in Armenia to perform these difficult surgeries.

Roger called Dr. Tom Lee, an international ROP expert, who has been to Yerevan each year since 2010 with the EyeCare Project’s Medical Missions to train the ROP physicians how to diagnose and treat at-risk infants. Dr. Lee has been instrumental in developing the ROP screening and laser program which has resulted in a significant reduction in advanced ROP cases requiring surgery in Armenia. Dr. Lee has also established a telesurgery connection between the Children’s Hospital of Los Angeles and Hospitals in Armenia. Interactive lectures and supervision during surgery provided by pediatric academics in the United States to colleagues in Armenia, with highly specialized cameras and surgical equipment, has significantly impacted the lives of Armenian children.

Unable to travel to Armenia on such short notice, Dr. Lee referred Dr. Ohanesian to Dr. Chien Wong, a London-based pediatric specialist who is experienced in ROP surgery and related disorders. Dr. Ohanesian filled Dr. Wong in on the situation and, recognizing the urgency of the matter, Dr. Wong immediately rearranged his duties at Moorfield and Royal London Free Hospital and made plans to travel to Armenia.

While Drs. Ohanesian and Wong were making their arrangements and traveling, the EyeCare Project’s ROP surgical team in Yerevan was making preparations to operate on the babies. The doctors met in Yerevan late Saturday night and saw all of the babies on Sunday in the Neonatal Intensive Care Unit.

They had an enormous task ahead of them — 18 complicated surgeries on the tiniest of patients and very little time. Dr. Wong, lead surgeon, Dr. Ohanesian and the Armenian ROP team — Dr. Adik Hovhannisyan, Dr. Hasmik Haratunyan and Dr. Ruzanna Haratunyan — performed multiple, extremely difficult surgeries. One surgery, on a five-month-old infant, required nearly four hours to complete.

While Dr. Wong taught the Armenian surgeons the delicate intricacies of his surgical techniques and endoscopy — operating from within the eye — Dr. Lee was at his home in California, electronically connected to the operating suite. He was able to view the exact images seen through the endoscope and surgical microscope and to advise the surgeons in real time during the surgeries. Despite the 12-hour time difference and surgeries lasting well past midnight in California, Dr. Lee participated for two days providing invaluable training for the Armenian physicians.

Soon after the first surgeries were complete, Dr. Hovhannisyan took over as lead surgeon and Dr. Wong assisted. Dr. Ohanesian said these were the worst cases of abnormal intraocular vascularization he had seen in 40 years of practice.

The day following the surgeries the exhausted physicians examined their patients and all of the babies were doing well — a lifetime of darkness averted. Since the development of the Project’s ROP Program in Armenia, with physician training, extensive screening of all premature infants in the NICUs and laser treatment of those found to have ROP, the EyeCare Project has been able to reduce ROP-related blindness in infants by more than 90 percent — from approximately 60 infants per year to little more than six.

Retinopathy of Prematurity (ROP)
The EyeCare Project established an ROP Program in Armenia in 2010, to treat infants and young children afflicted with this devastating and potentially blinding disease. ROP affects the developing vessels of premature infants between the eighth and ninth month of pregnancy. These abnormal blood vessels grow and spread throughout the retina — the paper thin tissue that lines the back of the eye — causing blindness.

The risks of Retinopathy of Prematurity have been known in the United States for decades. First encountered in the early 1950s, an epidemic of ROP left an estimated 7,000 American children blind in one year alone. In Armenia — a country the size of Maryland landlocked between Iran, Turkey, Azerbaijan and Georgia — awareness has come only recently. As the health care infrastructure is advancing in Armenia, with improvements in the medical care of smallest premature infants, the rate and severity of ROP have increased. Previously, infants did not live long enough to show the effects of ROP. With higher levels of oxygen in their incubators they survive, but develop ROP.

Now, every year in Armenia, many children are born prematurely and survive because of advanced care in the NICUs, but tragically grow up blind because of ROP. Approximately 60 percent of children in a neonatal intensive care unit will go on to develop some degree of ROP and 10 percent will progress to the advanced form even with laser treatment. Without surgery more than half of the children with the advanced form will go on to develop irreversible blindness. This process can occur in as little as one to two weeks.

The first treatment for ROP is a non-invasive laser therapy that can be performed at the child’s bedside in as little as 30 minutes. One treatment is generally sufficient to produce complete regression of ROP if it is performed in a timely fashion. The success rate overall is 90 percent, although in the most aggressive form of ROP, the success rate falls to 50 – 70 percent. In those cases where laser is not enough

To halt the progression of the disease, surgery is necessary to physically remove the residual scar tissue that remains and tugs on the retina.

With Dr. Lee’s telesurgery medical education program, Armenian doctors are able to receive ROP surgical training that is the equivalent of a medical residency or fellowship. The Armenian physicians scan the retinas of infants in local NICUs and send the images to The Vision Center at Children’s Hospital in Los Angeles via the Internet. Experienced pediatric ophthalmologists at the Vision Center review them and discuss the appropriate treatment with the Armenian physicians.

Dr. Wong will travel to Armenia again in July and September to train the Armenian physicians and to perform surgeries. Dr. Wong will assume the role of assistant surgeon while the Armenian retinal surgeons with the Project’s ROP team will be the primary surgeons. The long-range goal of the EyeCare Project is to have the Armenian physicians reach a level of competence equal to that of retinal surgeons in the United States so they will be able to perform independently.

In September, the EyeCare Project will host an international conference on the diagnosis and treatment of ROP. Pediatric ophthalmologists and retinal specialists from CIS and other countries will attend. A number of these countries have sent their patients to the Armenian ROP Center for treatment, which has been designated as a “Center of Excellence” by the United States Agency for International Development (USAID) and the United States Ambassador to Armenia, John S. Heffern.

The Armenian Eye Care Project
The Armenian EyeCare Project, a nonprofit organization founded in 1992, by Dr. Roger Ohanesian, is based in Orange County, CA. Their mission is to eliminate preventable blindness in Armenia and to provide access to eye care for all Armenians. This is accomplished through a comprehensive, integrated approach with medical education and training as the cornerstone. Components of the program include eight specialty clinics and a mobile eye hospital that travels throughout the country.

Initially, the Project provided eye care for those wounded in the Nagorno-Karabakh War that Armenians fought with Azerbaijan from 1988 to 1994. After the war Ohanesian redirected the project toward conducting specialized trainings for Armenian ophthalmologists and providing eye screenings and eye surgery for isolated and vulnerable members of the population with a Mobile Eye Hospital that travels throughout Armenia. The ROP program was added to the mix of eye care programs after learning that better neonatal care was increasing the survival chances for Armenian preemies, but lack of proper eye screenings meant many were going blind. In 2010, he recruited Dr. Tom Lee, chief of Vision Sciences at Children’s Hospital Los Angeles, to travel to Yerevan and to teach ophthalmologists how to diagnose and treat ROP. www.eyecareproject.com

The Vision Center
The Vision Center at Children’s Hospital Los Angeles is an international referral center known for its family friendly environment of children afflicted with all forms of eye disease and provides a full range of inpatient and outpatient services. It is the largest pediatric ophthalmology program in the nation with multiple subspecialty programs that are considered to be among today’s finest resources for diagnosis, treatment and research. Children’s Hospital Los Angeles is one of America’s premier teaching hospitals, affiliated with the Keck School of Medicine of the University of Southern California since 1932. It is a national leader in pediatric research.